The form for notice of changes in criminal history record requires:

1. (1) the name of the individual;
2. (2) if a commissioned notary public, the notary's commission number;
3. (3) the last four digits of the individual's SSN;
4. (4) contact information for the individual;

5. (5) for a previously unreported criminal charge:

   1. (a) the date of the charge;
   2. (b) the court in which the charge is filed;
   3. (c) whether the charge is for a felony or misdemeanor;
   4. (d) the name of the charge;
   5. (e) whether the charge has been set for a hearing or trial and, if yes, the scheduled date; and
   6. (f) the case number;

6. (6) for notice of a disposition of a criminal charge:

   1. (a) the date of the disposition;
   2. (b) the name of the court and the case number;

   3. (c) if the disposition resulted in a conviction:

      1. (i) whether the conviction was for a felony or misdemeanor; and
      2. (ii) the sentence imposed;
   4. (d) a copy of the disposition document or judgment;
   5. (e) a copy of any document restoring citizenship rights;
7. (7) a declaration under penalty of perjury that the information provided is true and complete to the best of the affiant's knowledge and belief; and
8. (8) the signature of the individual and the date signed.

History Note: Authority G.S. 10B-4;
Eff. July 1, 2024;
Amended Eff. July 1, 2025.